Organization
CHILDRENS DENTISTRY OF LITHONIA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ADESEGUN OLUSHOLA TEWOGBADE DMD (OWNER)
(770) 469-4192
Entity
Organization
Contact information
Practice address
374 C NORTH DESHON ROAD, STONE MOUNTAIN, GA 30087
(770) 469-4192
(770) 469-4195
Mailing address
PO BOX 870272, STONE MOUNTAIN, GA 30087-0007
(770) 469-4192
(770) 469-4195
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
DN013400
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1952449944
INDIVIDUAL NPI
—
05
—
853805701A
—
GA
Enumeration date
06/09/2008
Last updated
06/09/2008
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